O’Connor M, Kosatsky T 1 Systematic review: How efficacious and how practical are personal health protection measures recommended to reduce morbidity and mortality during heat episodes? Madeline O’Connor, M.D. and Tom Kosatsky, M.D. With the collaboration of Lynn Rusimovic, M.D. D.S.P. de Montréal (Montréal Public Health) For Ouranos (the Consortium on Regional Climatology and Adaptation to Climate Change) and The National Collaborating Centre for Environmental Health (NCCEH) February 28, 2008 Production of this document has been made possible through a financial contribution from the Public Health Agency of Canada through the National Collaborating Centre for Environmental Health. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada or the National Collaborating Centre for Environmental Health. O’Connor M, Kosatsky T 2 Abstract: In this review we aim to establish what health protective advice is offered by public health and civil protection authorities in general and specifically during heat episodes. We have evaluated the incoherencies and discrepancies of health messages given by various sources and critically assessed the efficacy of this advice by reviewing current evidence supporting these measures on the basis of observational studies and from the physiology of heat response. Firstly, we performed an internet search intended to replicate the results found by a typical member of the general public looking for local heat health advice from local health departments of or more authoritative sources in anticipation of a coming heat wave, or during one. We identified 60 public health, disaster relief, weather service, and patient advocacy websites between June 2006 and March 2007 and 44 documents were identified which gave heat-specific health advice. After classifying and ranking the advice messages, we selected six topics chosen on the basis of inconsistency in messaging among agencies, vagueness or ambiguity as to message targets or instructions, or where optimal messaging appeared most likely to protect health. In order to explore these areas in more detail, we systematically examined peer- reviewed articles to support, refute, and contextualize the recommendations given (acclimatization, air-conditioning, fan use, medications, hydration, and activity reduction). For this strategy, we searched Medline, PubMed, and hand-searched references of identified reviews and articles, consulted colleagues and internet search engines (Google Scholar). By reviewing the relevant epidemiological, physiological, and experimental studies in each area, we were able to draw conclusions and highlight areas where more research needs to be done. Among the insights gained from this undertaking, we were able to identify advice that was practical, notably increasing hydration, monitoring those taking medications that disrupt heat responses, acclimatizing slowly to the heat, reducing activity level and using electric fans to enhance evaporative cooling or supplement other cooling techniques. Some of the advice which was not well supported by scientific evidence was avoidance of fan use, avoidance of caffeinated and sweetened drinks, and avoiding all alcoholic beverages. Areas where knowledge gaps exist were found concerning the use of devices other than air conditioning to enhance cooling and ventilation, hydration and activity needs and limitations of heat-vulnerable populations, and the level of risk presented by commonly taken medications during heat waves. O’Connor M, Kosatsky T 3 Systematic review: How efficacious and how practical are personal health protection measures recommended to reduce morbidity and mortality during heat episodes? Introduction The potential impact of elevated temperatures on mortality and morbidity are severe. In the U.S., for example, from 1979 to 1999, the deaths of 8,015 Americans have been directly associated with excessive heat exposure (CDC, 2002). As recently as August 2006, there were over 100 heat-related deaths during one week in New York City (Perez- Pena, 2006). These US estimates undercount the full impact of heat, however, as there are no widely accepted criteria for determining a heat-related death, and death certificates often do not identify when heat has acted as a contributing factor in exacerbating pre- existing cardiovascular, respiratory, psychiatric and other conditions (Basu & Samet, 2002). A broader impact of heat is suggested by the observation that every year, hospitalizations and deaths in numbers well above average, occur during and just after days of extreme heat, particularly in vulnerable populations. In 2003, Western and Central Europe experienced the hottest summer since 1500, and the heat wave in early August caused an estimated 14,800 deaths in France alone (Sardon J-P, 2007). Urban Canada has also been affected: a 1994 heat wave in Montreal led to over 100 excess deaths (Kosatsky T, Henry B, & King N, 2005). Persons over the age of 65 consistently show the highest rates of heat-related mortality. Persons living in urban environments may be at particularly increased risk for mortality from ambient heat exposure, since urban areas are typically warmer than surrounding suburban or rural areas, a phenomenon known as the “urban heat island effect”. Other vulnerable groups identified as being susceptible to heat-related mortality are: infants and children up to four years of age; persons in poor general health – especially those with cardiovascular, neurological and psychiatric conditions, endocrine disorders and chronic pulmonary disease, liver and kidney diseases or high blood pressure; persons who take medications that aggravate dehydration and heat exhaustion, such as diuretics, neuroleptics, antidepressants, benzodiazepines, amphetamines, analgesics, beta-blockers, ACE inhibitors, anti-inflammatory drugs and many others; persons who are overweight; those who are socially isolated; persons who overexert during work or exercise; and those confined to bed and unable to care for themselves . With a world of both warmer summers and climatic instability, and given an aging population, increasingly more isolated and more medicated, efficient measures to reduce the risk of heat-related death are crucial. Various expert bodies have promoted measures designed to decrease vulnerability to heat-related death, and to provide early recognition of and first aid to persons affected by heat. Among these organisations are the World Health Organisation , the US Environmental Protection Agency , the US Centers for Disease Control, the French Institut de Veille Sanitaire, the UK Department of Health, and many state and city O’Connor M, Kosatsky T 4 departments of public health, including those for Toronto and Montreal. Professional organisations such as the American Pediatric Association have also published guidelines for the protection of health in the heat (Anderson, Griesemer, Johnson, American Academy of Pediatrics, & Committee on Sports Medicine and Fitness, 2000). Sport medicine, the military, and occupational health bodies have also produced guidelines, which are of particular interest given their emphasis on work in the heat, and on optimal clothing for the heat, which are of relevance beyond the realms of sport, work, and war. Objectives 1. To establish what health protective advice is offered by public health and civil protection authorities in general and specifically during heat episodes. 2. To review current evidence supporting these measures on the basis of observational studies and from the physiology of heat response. 3. To critically assess the efficacy of this advice and review the incoherencies and discrepancies of health messages given by various sources. 4. To identify knowledge gaps that may limit our ability to evaluate these measures. 5. To assist clinicians and public health professionals in developing health protection measures most likely to protect the population from the adverse effects of heat. Methods Individual health protection measures identified *Numbers in bold (1) refer to websites identified in Appendix A Our internet search was intended to replicate the results found by a typical member of the general public looking for local heat health advice (metropolitan and provincial health departments) or more authoritative sources (World Health Organization, CDC) in anticipation of a coming heat wave, or during one. Many sites provided links to other sites within their own agency where one could find recommendations targeted to the elderly, parents of young children, athletes, or outdoor labourers (6, 21, 31, 33). We included those sites aimed at the general public and those aimed at the elderly and caretakers of heat-vulnerable people. We performed a systematic search of web- accessible advice for protection against heat-related illness available to the general public in North America, Europe and Australia. Our search criteria are summarized in Table 1. We searched seven categories of websites which include public health or civil protection agencies most likely to provide authoritative health protection advice. A complete list of websites searched can be found in Appendix A. From these sites, were able to distinguish 12 basic categories of commonly recommended health protection measures pertaining to staying cool, well hydrated, reducing heat stress, and seeking help from appropriate sources. O’Connor M, Kosatsky T 5 Table 1. Selection criteria to identify health protection measures against heat- related illness Included